Rochester Institute of Technology RIT Scholar Works
Theses
2000
Telemedicine application at the University of Rochester Medical Center Strong Memorial Hospital in conjunction with the New York State Department of Corrections
Jeannine Christensen
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Recommended Citation Christensen, Jeannine, "Telemedicine application at the University of Rochester Medical Center Strong Memorial Hospital in conjunction with the New York State Department of Corrections" (2000). Thesis. Rochester Institute of Technology. Accessed from
This Thesis is brought to you for free and open access by RIT Scholar Works. It has been accepted for inclusion in Theses by an authorized administrator of RIT Scholar Works. For more information, please contact [email protected]. Telemedicine Application at the University of Rochester Medical Center Strong Memorial Hospital In Conjunction with the New York State Department of Corrections
By
Jeannine L. Christensen
Thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in Information Technology
Department of Information Technology Rochester Institute of Technology
November 2000 Rochester Institute of Technology Department of Information Technology
Master of Science in Information Technology Thesis Approval Form
Student Name: Jeannie L. Christensen
Student Number: ------
Thesis Title: A Telemedicine Application at the University of Rochester Medical Center Strong Memorial Hospital in Conjunction with the New York State Department of Corrections
Thesis Committee
Name Signature Date
Prof. Rayno Niemi Chair
Prof. Anne Haake Committee Member
Mr. Michael Myers I((S/to Committee Member Wallace Library Rochester Institute of Technology
Thesis Reproduction Permission Statement
Permission From Author Required
Telemedicine Applications at the University of Rochester Medical Center (URMC) Strong Memorial Hospital (SMH) And A Practical Implementation in conjunction with the New York State Department of Corrections (NYSDOC)
I, Jeannie L. Christensen, prefer to be contacted each time a request for
reproduction is made. Due to some confidential and sensitive information in
this document, certain permission will have to be obtained from both the
University of Rochester and the New York State Correctional facility. If
permission is granted, any reproduction will not be for commercial use or
profit. I can be contacted at the following address:
438-H Browncroft Blvd. Rochester, New York 14609 Email Address:[email protected] Voice Number: (716) 588-4493 or (716) 482-9059
Date: October 30, 2000
Signature of Author:
Jeannie L. Christensen Page 1 of 81 Capstone Thesis Acknowledgement
This is dedicated to my three lovely daughters, Christal Jean Maria Jeannette Rebecca Jean They have been patient enough....
To all of the staff of the Department of Information Technology at Rochester Institute of Technology for making my learning experience so
memorable and enjoyable . To dear Prof. Niemi who
never gave up on me. To Prof. Haake for taking on my case at a short notice and being so
supportive . To Mike Myers for being such a good
friend and colleague .
I would also like to thank Tim for always
reminding me of my priorities in life and provided the daily encouragement and support I needed.
Finally, to all of my friends, who had unrelentlessly gave their support to finish writing the thesis....
Medicine is here so that the patients survives, not the doctors.
Jay Sanders, M.D. Telemedicine Day, April 28, 1998 University of Rochester, Strong Memorial Hospital Rochester, New York
Jeannie L Cr fensen Page 3 of 81 Capstone Thesis Abstract
Telemedicine has been around for several years and it is inevitable
that this technology will shape the current healthcare environment. Doctors
are often faced with the challenges of the laws of time and distance. With the
presence of telemedicine, the idea of having access to a physician at any
given time becomes a reality. This paper will present an exciting concept of
telemedicine for today and tomorrow with an emphasis on the advancement
of health care delivery systems.
This thesis will also attempt to present the cost saving factors that
telemedicine can provide not only to patient care but also to the financial and
administrative aspects of healthcare. It will provide a summation of goals,
design description and the initial cost of implementing a telemedicine
application.
This paper will be a combination of discussions on general
telemedicine applications and a practical implementation. It culminated with a
presentation of an actual telemedicine project that the University of Rochester
Medical Center implemented in conjunction with the New York State
Department of Corrections telemedicine project. I was a member of the team
"true" that designed and implemented the first telemedicine application for
Strong Memorial Hospital.
Jeannie L. Christensen - Page 4 of 81 Capstone Thesis It consists of an outlined discussion as presented on the Table of
Contents and the networking design proposal to implement a telemedicine
project.
The paper also investigated some other telemedicine applications at
the University of Rochester Medical Center that can be implemented in the
future. We tried to follow a rigid timeline, but due to some delay on procuring
the leased line we fell a little behind on the implementation. The committee
for Telemedicine in Strong Memorial Hospital met on a regular basis and
assessed the technological needs of each department. Below was the
tentative timeline for the project itself. The dates changed based on how
promptly the vendors were able to meet the project requirements:
March 30, 1998 - T1 Installation
March 15-20, 1998 - Support Staff Training
April 15, 1998 - Test Phase
April 30, 1998 - Final implementation
My primary role in this implementation is to design the wide and local
area network for the University of Rochester Medical Center. I also
participated in several of the committee meetings which outlines other
administrative issues involved, such as the emergency room renovations,
feasibility of extending video conference services, discussions on cost and
billing issues, and a visit of an actual correctional facility to observe its
telemedicine application.
Jeannie L Christensen Page 5 of 81 Capstone Thesis GOALS AND OBJECTIVES
To maintain a leading edge as an academic and clinical institution, the
University of Rochester Medical Center has given serious consideration to
procuring telemedicine technology. The telemedicine project has enabled
"visit" hospital physicians to connect with remote sites and with the patients in
some of the correctional facilities in New York State, e.g. the Albion
Correctional Facility. This project was also utilized to link to other regional
hospitals for grand round presentations, clinical consults and patient triage,
enroll patients in clinical trials, and educational training and administrative
conferencing. The project provided a much-needed presence for Strong
Memorial Hospital within the region.
The initial telemedicine implementation was to be the trial project that
will provide the hospital management with a basis for approval of further
telemedicine funding. The initial project was funded fully by the hospital
administration and will be re-evaluated within a year for future applications
and financial support.
The overall goal was to develop a telemedicine network which will
provide consultative support to the NYS Department of Corrections, and to
evaluate this network as to its feasibility, utilization, patient acceptance and
satisfaction, and cost.
Jeannie L. Christensen Page 6 of 81 Capstone Thesis Table of Contents
Introduction 8-9
A Brief History of Telemedicine 10-17
Telemedicine and its Driving Force 18-20
Advantages of Telemedicine 21-23 Integrated Consultation 21 Increase Patient Access 21 Improved Quality of Care 22 Reduce Cost 22-26
Disadvantages of Telemedicine 27 Technical Failure 27 Malpractice Suits 28 Security 28
Telemedicine Background at the University of Rochester Strong Memorial Hospital 29-33
Telemedicine Background at the New York State Department of Corrections 34-38
Project Description and Methodology 39 Participants 39-40 Requirements and Specification 40-41 Costs 41-43 Implementation 44-45 Standards and Protocols 45-48
Network Design 49 Phase 1 49-61 Phase 2 61-64
Discussions, Outcome and Measurement 65-69
Telemedicine Future/Direction at the University of Rochester Strong Memorial Hospital 70
Telemedicine and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) 72
Summary 75
Appendices 77-80 A Proposed Telemedicine Budget 77 B Summation of Proposed Telemedicine Projects 78-79 C New URMC Video Conferencing Network 80 Bibliography 81
Jeannie L. Christensen Page 7 of 81 Capstone Thesis What is important here is that telemedicine is a system without borders. It is not a new kind of medicine. It is a way of communication that makes it possible to utilize existing medical resources in a new and much more efficient way.
Steinar Pedersen, M.D. Head of the Department of Telemedicine University Hospital of Tromsoe, Norway
INTRODUCTION
In the healthcare industry, telemedicine is a growing business. It is a
medium to reach patients in need of health care who would otherwise be left
isolated. The telephone has helped telemedicine gain its popularity. It
offered the first and simplest application of telemedicine by providing the
physicians an instrument in closing the geographic gap in healthcare
services. They were able to respond immediately to both minor and major
patient complaints. Physicians were able to teleconference and discuss
patient cases without having to drive to remote areas. Then came television
and the ability to transmit images across a wire. The physicians were then
able to determine a diagnosis and a treatment without having to be present
with the patient.
distance" "Medicine at a is one of the most basic definitions of
telemedicine1. The technology involves a mixture of advanced
telecommunications equipment that is integrated with today's sophisticated
medical technology. With its many applications, medicine is made available
to many cities and rural areas all over the world.
Jeannie L. Christensen Page 8 of 81 Capstone Thesis The technology available for telemedicine has improved drastically
throughout the years. It is a continuing challenge and the healthcare industry
"information" is definitely a candidate for improvement in the areas of
highway. Competition has increased in the telecommunications business in
the last ten years providing a much wider product choices for telemedicine
applications. Yet, even with the breakup of AT&T in 1984, the industry
deregulation has discouraged business entry into dramatic new
telecommunications services because of the threat of government
interference or litigation among competing business interests2. All gears have
shifted with the government very interested in utilizing telecommunications
growth as a major economic goal. We now see an unleashing of investment
in the field of telecommunications and it's telemedicine applications.
Jeannie L. Christensen Page 9 of 81 Capstone Thesis A BRIEF HISTORY OF TELEMEDICINE
Dr. Kenneth T. Bird was the first big name in telemedicine when, in
1962, he developed a plan for "telediagnosis". It started when Dr. Bird
received a call reporting that an older woman had seriously injured herself in
a fall and was not allowed to be moved. Part of Dr. Bird's frustration was not
being able to consult with the patient at the Massachusetts General Hospital.
He would need to travel hundreds of miles. This gave him the vision of being
able to watch the patient on television.
With a grant from the United States Public Health Service, Dr. Bird
planned to configure two television monitors and equip them with microwave
units. The units transmitted signals creating a full-motion interactive video
service. His first political battle was with The Federal Communications
Commission (FCC). The FCC delayed giving the permission to activate the
link until April 1 968 due to the fact that microwave channel was not yet an
acceptable transmission system.
The first patient to benefit from this new project was a patient who had
an acutely swollen left knee. The patient at the Logan Hospital was placed in
full view of the camera in Massachusetts General while the physicians
diagnosed the patient. The doctors were able to correctly diagnose the
patient with an acute "traumatic intrapatella bursitis". The patient was
prescribed treatment and medication over the television. In 1975, while Dr.
Bird was delivering a speech at the University of Michigan, he told the story of
Jeannie L. Christensen Page 10 of 81 Capstone Thesis when a patient, upon leaving the hospital, stated that it was as if he was
1 beside the physician.
Over the next few years, Dr. Bird became very active with the
telemedicine applications. Bird and several of his colleagues at
Massachusetts General tested the telemedicine application's reliability by
comparing remote diagnoses with those that were done on the same patients
via an actual hospital visit. The research showed that 98 percent of the
patient diagnoses, utilizing the unrefined interactive television, were accurate.
The other 2 percent could be blamed to doctors making conservative
diagnoses so as to protect the patient.
Later, there came other challenges from other departments. At
Massachusetts General, almost all the medical chiefs embraced the
technology, except for one Dr. Tom Dwyer, Chief of the Psychiatric
Department. He was convinced that telemedicine would not work for his
"cold" patients. According to Dr. Dwyer, the technology eliminated the real
feeling of warmth and ambiance that exist between patients and physicians.
"telepsychiatry" By securing another grant to implement a application,
Dr. Bird patiently provided proof that telemedicine could also be used for
psychiatric consultations. Amazingly, given the ability to miniaturize the
physical view of the psychiatrist in the background, the patients dealt with the
sessions more comfortably.
Other pioneering physicians followed Dr. Bird's vision and launched
several telemedicine experiments. Dr. A. Max House set up the oldest
Jeannie L. Christensen Page 11 of 81 Capstone Thesis continually operating telemedicine program in the world at the Memorial
University of Newfoundland (MUN). Utilizing the joint Canadian and United
States Hermes Satellite, he elected for a one-way television and a two-way
interactive audio configuration. Their efforts launched a terrestrially-based
teleconference in 1979 at a much lower cost. The program expanded in the
mid-eighties to include Africa and the Caribbean. The Satellites in Health
and Rural Education (SHARE) was formed in 1 985 by the International
Satellite Organization (Intelsat) and the International Institute of
Communications. Utilizing the SHARE project, the MUN Telemedicine Group
set up a telemedicine link between facilities in Nairobi, Kenya, and Kampala
linking those East African cities to MUN. The project lasted for 1 0 months but
resulted in the transmission of roughly 100 EEG's from East Africa to the
MUN staff. The satellite service was a free service offered by Intelsat. The
equipment at the remote site featured an electrode cap and transmitter. The
transmitter converted the brain wave patterns to analog signals in the voice
bandwidth for transmission over the network. In 1986, MUN took the project
another step and linked six Caribbean countries on the University of the West
Indies teleconference system. This extended project lasted only for six
months but it did offer the foundation for a successful data and voice
transmission design called the Intra-Jamaican project.
Another milestone in the history of Telemedicine is the development of
the "Telemedicine Spacebridge". It started in December 7, 1988 when a
massive earthquake devastated Soviet Armenia. 25,000 died and 125,000
Jeannie L. Christensen Page 12 of 81 Capstone Thesis people suffered head and spinal injuries, crushed limbs or organs, loss of
blood, and disfiguring wounds. Armenia's medical system was overwhelmed
and at the same time many of the health care providers were among the dead
or injured. Many of the Soviet Union doctors were rushed to the scene to
assist with the devastation. NASA proposed to the Soviet government that
the two nations could activate a satellite-based medical consultation network.
its goal was to transmit expertise to Soviet medical personnel in areas where
they had an expressed need, i.e. re-constructive surgery, physical and
psychological rehabilitation, public health and epidemiology. The program
was put under the auspices of the existing bilateral Space Agreement
between the United States and the Soviet Union concerning the Exploration
and Use of Outer Space for Peaceful Purposes.
The program was also plagued with political issues as well as deeper
questions concerning the medical aspects of the program. The teams from
both countries were forced to develop new standards for medical information
transmission, as well as protocols and schedules on conducting
consultations. Both countries had to take reciprocal trips to the counterpart
country to investigate and learn more about the differences between their
medical processes. Five months after the last tremor stopped, an open and a
steady dialogue over a one-way video and a two-way audio link was
established. On May 4, 1989, both medical teams tackled the post-acute
rehabilitative needs of Armenia's sick and injured, and the slow process of
rebuilding Armenia's medical system.
Jeannie L. Christensen Page 13 of 81 Capstone Thesis On June 4, 1989, near the town of Ufa, North Russia, another tragedy
struck when two trains passed each other in a cloud of natural gas that was
leaking from a pipeline. The gas leak sparked an explosion, which killed
hundreds of people, and thousands more suffered burns and trauma. One of
the trains carried mostly children. Since telemedicine application has been
implemented in Armenia, it was easy to put a satellite clinic at the Ufa Medical
Center. The emergency group was then serviced by the Armenian and the
American medical group.
The Telemedicine Spacebridge lasted only until July 28, 1989 with an
official count of 210 cases discussed. NASA's partners included hundreds of
doctors from different university hospitals in Maryland, Texas, and Utah. The
Soviet medical partners included 60 lecturers at the Yerevan Medical Institute
of Advanced Physician Training and 50 directors of various medical
institutions. One of the major concerns of the doctors involved with the
project is the fact that having multiple specialists at multiple sites would lead
to confusion or even contradiction of one another's diagnoses, but the
opposite happened. Dr. Bruce Houtchens, a central figure in the Spacebridge
project, said that "The American physicians at least, said one of the things
they missed when the Spacebridge program was terminated with Armenia -
where we were, in fact, doing real patient consultations - was the lack of
fashion."1 contact and critique by their peers in a real-time, on-line
Even through the Telemedicine Spacebridge terminated, it opened the
future and 1 991 after gateway for implementation. In 1 990 , two international
Jeannie L. Christensen Page 14 of 81 Capstone Thesis telemedicine conferences, NASA and the Moscow Ministry of the Interior took
steps to establish a partnership. This partnership will allow for a steady
exchange of Russian and American medical expertise; and in 1992 a signed
agreement was produced between the United States telemedicine delegation
and the Russian officials that established the protocols for future
collaboration.
There are several countries that have provided telemedicine
experiments to further empower their physicians. In India, a telemedicine
project offered the promise of radically changing healthcare for the country.
About 80% of India's population, 700 million live in rural areas and medicine
is not readily made available to them. With the aid of telemedicine, the
specialists were able to communicate to these areas using two-way audio and
video equipment. Even if the application offered good results, it still fell short
in sound quality, therefore casting doubt on the credibility of some diagnoses,
such as specialists who listens for subtle shifts in the heart pitch and changes
in the skin tone. The physicians are concerned that even with a good network
may not be good enough or reliable enough.
In Australia, telemedicine conquered the vast distances that separated
many towns from modern health care. One challenge comes from the giant
state of Queensland, stretching 1,300 miles north-south and about 700 miles
east-west, the state was populated by only 30,000 healthcare providers. With
the assistance of a government sponsorship, the North-West Telemedicine
Project was implemented to serve five isolated towns in Queensland.
Jeannie L. Christensen Page 15 of 81 Capstone Thesis Norway also sanctioned telemedicine as a new and exciting adjunct to
face-to-face healthcare. Singapore's aggressive use of advanced
communication systems will make telemedicine an instant reality there, too.
All over the world, both the healthcare industry and the government are
collaborating to find ways to explore the telemedicine technology. It has been
proven that even if the initial implementation of a telemedicine project could
be costly, the advantages still outweigh the disadvantages.
Dr. Jay Sanders is nationally recognized as a telemedicine pioneer and
a very active advocate of improved access to healthcare services. He was
the President of the American Telemedicine Association for two years and
stepped down from his post on April of 1998. He still continues his work as a
vice-chairman of the Rural Health Care Corporation. The RHCC is a FCC
appointed agency administering mandated telecommunications discounts to
rural providers. Dr. Sanders is also the President of The Global Telemedicine
Group in McLean, Virginia. In the course of my working on this thesis, I had
the privileged of meeting Dr. Sanders and witnessed his true dedication to the
technology.
Jeannie L. C stensen Page 16 of 81 Capstone Thesis Photo 1: Dr. Jay Sanders & Dr. Alice Pentland during the Telemedicine Day at Strong Memorial Hospital
Jeannie L. Christensen Page 17 of 81 TELEMEDICINE AND ITS DRIVING FORCE
The current technology of telemedicine has proven that it does improve
health care delivery and have paved the way to widespread adoption. It
provides easy access to health care and has been instrumental to hundreds
consultations.13 of collaborative research and For years, the continuing
melee on regulation and government interference has discouraged many
healthcare institutions and business to enter the world of telemedicine (refer
to section on HIPAA for governmental issues).
Telemedicine today has become a major key player in the field of
information technology. One would be curious if the demand for sophisticated
telemedicine applications drives our insatiable taste for advanced and
improved technology or vice versa. The need for high quality health care is
one of the driving forces of telemedicine, enabling to close the gap between
the patient and the healthcare providers. Implementing a telemedicine
project has also been less cost prohibitive. With the rise in competition
between telecommunication service providers, accessing the information
highway became uncomplicated and less tedious. Prices for
telecommunications access has become very competitive and cost effective.
There has also been a major shift in the patient mentality. Gone are
the days of uninformed patients. The Internet, having been made available to
the major part of the population, offers an inexpensive form of communication
between the healthcare providers and their patients. Today, there is an
Jeannie L Christensen Page 18 of 81 Capstone Thesis increase demand from the public for patient information and records to be
made accessible. Patient education has been a focal point of most
treatments. By educating the patient with the success rate and risk factors,
the physician transfers a new sense of responsibility to the patient.
Telemedicine enables the transfer of this knowledge right to the patient's
living room. The Internet also provides medical institutions an inexpensive
and readily available test bed for the commercialization of telemedicine
technology.
Telemedicine has stirred interest in all sectors of the business.
Vendors, such as PictureTel, RadVision, and Lucent are investing heavily in
"videoconferencing" the technology and shifted the focus not only on their
features but also promotes their telemedicine applications. Healthcare
institutions are making sure that they are not behind the times and are also
investing in telemedicine implementation to position themselves competitively.
Meanwhile, the regulatory bodies, such as the Federal Communication
Commission (FCC) and HIPAA (Health Insurance Portability and
Accountability Act of 1996) are making sure that there are laws and policies in
place (refer to section on HIPAA).
The Internet has also been made widely available and has become a
usable transmission system for a lot of the telemedicine deployments. The
challenge is to balance its commercialization with security and affordability.
The current growth of the Internet is consistent with other services made
Jeannie L. Christensen Page 19 of 81 Capstone Thesis available to telemedicine such as speech recognition, centralized clinical
systems, and speech translation.
Telemedicine is here to stay and its one answer to our need to improve
the overall administration of healthcare. It could only move forward and more
accepted. Its continued success will rely on both national policy and the
overall public mentality towards the technology.
Jeannie L Christensen Page 20 of 81 Capstone Thesis ADVANTAGES OF TELEMEDICINE
Aside from the obvious time-saving and distance-reducing benefits,
telemedicine offers a variety of other benefits.
Integrated Consultation: In a traditional consultation, where several
physicians are involved, keeping the patient record updated poses a problem.
The patient has to have a visit with each physician and each physician must
update his own records. According to the Institute of Medicine, about 70
percent of the hospital records are incomplete; 30 percent of the physicians
have limited access to the patient records; and approximately 22 people in
hospitals depended on access to patient records at a given time. In a
telemedicine consultation, the referring physician, consulting specialist, and
the patient are often together for the consultation. This is further enhanced
with the automated medical information systems providing easy access to
oatient records. After a telemedicine consultation, the patient data can be
entered onto an electronic patient database, which can also include the
physician diagnosis. Each patient has a medical record in a clinical database
system, which can contain demographics, medical history and even the
patient's laboratory results. The computerized medical record keeping also
erifies gaps in medical information and checks for any obvious
iconsistencies.
Increase Patient Access: One obvious benefit of telemedicine is
patients regardless of For due to government raching distance. years,
Jeannie L. Cl risen Page 21 of 81 Capstone Thesis regulations on telecommunication policies, technology was slow to catch up
with the demands of telemedicine. Acceptance within the medical community
was only half of the battle. Providing the transmission systems to connect
remote areas was another challenge. The forms of transmission of data or
information across the wire have slowly improved. Today, telemedicine can
enjoy several choices of transmitting its information via Satellite
connection, T1 to T3 line connection, Integrated Services Digital Network
(ISDN) lines, or even the regular analog lines (Appendix C). Telemedicine
aided in reducing medical isolation and has provided access to healthcare in
previously unserved or underprivileged areas.
Improved Quality of Care: Because of the integrated form of
consultation, with the patient and physicians consulting simultaneously, it
provides the synergy derived from a healthcare team approach. The patient
is encouraged to tell his symptoms directly to all the physicians and the
physicians apply a synchronized plan of action. It fosters greater patient
involvement, enhances compliance to treatment and it increases patient
knowledge.
One beneficial application is the ability to record the consultation
in full-motion video. This allows the physicians to review the session
repeatedly, if necessary. With patient permission, it can also be used for
future reference. There is also the ability to freeze a frame of the video exam
record. This will have special benefits in pediatric medicine, where a sick
two-year-old may not respond to a doctor's command to "sit still". Also, the
Jeannie L. C - Jensen Page 22 of 81 Capstone Thesis ability to automatically access on-line medical literature services such as the
Scientific American Medicine Consult (SAM). Aside from transmitting a
treatment program for a particular case, the consulting specialist could also
send relevant literature regarding the case. Some of the benefits of
telemedicine that affects the quality of care are as follows:
An electronic data processing technique that offers a more
sophisticated analysis of health care utilization and clinical outcomes.
It provides electronic administration and billing for services that
extends the cost savings to patients.
Computer-based decision support tools that can help reduce variation
in health care quality across providers, improve adherence to
standards of care, and reduce costs by eliminating duplicative or non-
efficacious tests and therapeutic procedures.
Introduced many telemedicine programs that overcome geographic
boundaries between patients and healthcare providers. It provides
electronic search engines of health issues both for the patient and the
healthcare provider.
Reduced Cost: Cost for travel includes both time and money.
Telemedicine provides patients access to specialty care without having to
providers access to travel to specialty clinics. It offers healthcare medical
video conferencing without having to travel for continuing education, therefore
cost. Healthcare institutions eliminating distance issues and travel have
Jeannie L. Christensen Page 23 of 81 Capstone Thesis reduced their cost by combining their emergency services using telemedicine;
such is the goal of the University of Rochester Medical Center telemedicine
applications. There is really no authoritative standard for calculating cost
savings when implementing a telemedicine project. A general formula have
been developed that compares costs incurred to costs saved and productivity
recovered. To make these calculations, it is important to record utilization in a
monthly user's log.
Names and Positions of all Participants
Record Every use of the System
Length of each Connection
Names of all Sites Connected during a call
In addition to these data, one-time calculations must be made for the following:
Travel Distance to Each Site (fuel or mileage reimbursement)
Travel Time to Each Site (lost productivity per person)
Salary Range for Each Position
Costs for usage and equipment
Savings can be determined by comparing the cost of owning and
reduced travel and operating the system against the costs saved by
r to other sites). This calculation increased productivity (time 3t spent traveling
services at several has been used to justify com nuation and expansion of
Telemedicine Association suggested this health care facilities. The A erican
cost-saving formula:
- (Equipment Savings = (Travel : osts + Time) +Telecomm)
24 of 81 Capstone iQanniR L. Christensen Page Thesis (The equipment must be amortized over time and the costs for travel must
14 include travel reimbursement and travel time for each participant)
According to recent statistics from the department of justice, the cost of
providing outpatient care to the prison populations has been estimated to be
as high as $1 ,000.00 per inmate visit. The cost varies considerably
depending on the type of medical care received, the number and salaries of
the security officers and the drivers involved.
We can apply this formula with the NYSDOC and URMC telemedicine
implementation. Most of the outpatient care for inmates are done during
normal business hours which leaves 240 days per year. Per inmate visit
averages 4 hours, inclusive of travel time, wait time and actual consult time.
Based on this estimate, an outpatient care for an inmate will roughly be:
Min. of 4 hours x $15/ hr/security officer = $60.00
$60 x 3 security officer = $1 80.00
Attica to Rochester = approximately 120 miles round trip
120 miles @ 0.32/mile = $38.40
I used $0.32 per mile because it is the federal standard mileage cost
assume initial normally used for tax purposes. It is safe to that the investment
for the telemedicine equipment would be good for seven to ten years before it
gets obsolete. Based on the proposed budget as outlined on Appendix A,
the capital cost for the Emergency Department is broken down to:
Total cost = $49,593.00 / 7 years = $7,085.00 / 240 days = $30.00
Jeannie L. Christensen Page 25 of 81 Capstone Thesis Recurring Telecomm Monthly cost = $419.96 / 30 days = $14.00
Following the suggested formula, there will be an estimated $152.00
savings per inmate outpatient care visit.
Savings = (Travel Costs + Time) - (Equipment +Telecomm)
= ($180.00 + $38.40) - ($30.00 + $14.00)
= $218.40 -$44.00
= 174.40
Page 26 of 81 Capstone Thesis jeannieLChristensen___ DISADVANTAGES OF TELEMEDICINE
As any other healthcare issues, telemedicine has its share of
concerns. Because modern technology is a major part of these projects,
there can be many impediments. In today's healthcare, physicians are forced
to routinely collaborate with computers, imaging devices, electronic
communicators, or even robots. In some cases, orthopedic surgeons have
worked hand-in-hand with robotic hip replacement specialists.
Technical Failure: There is always the danger that hardware and
software alike can fail. A loose screw in a robot can render the device
unusable, or a software malfunction in a Fetal Monitoring system can cause
the data to be unacceptable. These are valid concerns in both a normal
surgical operation or in a virtual-reality assisted telepresence surgery. But the
fact remains that overall, the practice of medicine is prone to human errors.
Mechanical failures, although unforeseeable, are often adjusted by providing
redundant equipment or a fault-tolerance connection. It can be avoided with
properly trained personnel, frequent calibration of equipment and
implementation of an emergency backup plan. There is also the constant
need to keep skilled technical staff and a need to train the medical community
on how to effectively use the system. It is not an easy task but it has to be in
place upon implementation and should be maintained if one has to keep up
with the telecommunication technology changes.
Ifiannie L. Christensen Page 27 of 81 Capstone Thesis Malpractice Suits: This is one of the major concerns with the new
telemedicine technology. With telemedicine practice becoming more
common, there are possibilities of an introduction of new legal soft spots in
the healthcare community. For this reason alone, more physicians are
alienated by the technology. In the United States, for example, the average
physician has 37 percent chance of being sued at some time in his or her
career. This increases to 52 percent for a surgeon and 78 percent for
obstetricians.1 Legal issues will always plague any medical procedure, but
with telemedicine procedures there could be a more aggressive form of
collecting data to support any malpractice suit. Dr. Jay Sanders states that:
"For the first time, we're opening up communication modality as a potential
source of misinformation. We now not only have a written record, we have a
consultation." visual record, we have an audio record of the entire
Security: This is a main concern in any healthcare institution.
Hospitals need to advocate patient confidentiality. With patient records
having to traverse the information highway, telemedicine projects are faced
with providing security measures to insure that none of the data will fall
openly to malicious hands. Most hospitals offer two-level access controls for
their telemedicine operators and administrators, one password for access to
the server and another for the individual database. Also, the government
came out with new policies to protect any patient information being sent out
using the information highway.
Christensen Page 28 of 81 Capstone Thesis Jeannie L. . TELEMEDICINE BACKGROUND AT THE UNIVESITY OF ROCHESTER, STRONG MEMORIAL HOSPITAL
The 750-bed Strong Memorial Hospital is the primary teaching hospital
of the University of Rochester School of Medicine and Dentistry and School of
Nursing. Further, it serves as the tertiary care hospital for the Finger Lakes
Region of Upstate New York and has been designated by New York as the
region's Trauma Center. In addition to its primary care services, the hospital
offers a variety of specialized services including high risk obstetrics and
gynecology; bone marrow transplantation; liver, kidney, and pancreas
transplantation; magnetic resonance imaging; kidney stone lithotripsy;
comprehensive pediatric care; a burn unit; and comprehensive epilepsy
treatment. Strong Memorial hospital's affiliation includes more than 1 ,000
physicians and more than 6,000 other health care providers and support staff.
The business unit at the University of Rochester Medical Center
(URMC) realizes that in order to maintain a leading edge as an academic and
clinical institution, serious consideration must be given to procure
telemedicine technology. An initial committee was formed in early 1997 to
look at valid applications of telemedicine for Strong Memorial Hospital.
Although there exists some telemedicine applications within the hospital,
there has really not been a real application implemented involving remote
accessing.
Jeannie L. Christensen Page 29 of 81 Capstone Thesis On June, 1994, a telemedicine task force convened to develop a vision
for telemedicine at Medical Center. A demonstration was done between
Strong Memorial Hospital and Noyes Hospital, in Dansville, which provided a
first look on a telemedicine application. There was a time around March of
1995 when the Office of Rural Health Policy (OHRP) offered funding to
evaluate telemedicine projects but the funding fell through. At that time, there
was also a lack of faculty support in some required clinical specialties. By
August of 1995, the United Medical Network was contracted to conduct a
telemedicine assessment and recommend a network solution for 8 hospitals
and 4 health care centers. Site visit was scheduled for October and a report
done in November.
As early as December 29, 1996, a proposal was sent out to the New
York State Advanced Telecommunications Project. The Strong Memorial
Administering Remote Telemedicine (SMART) was to provide an Integrated
Service Digital Network-Bit rate Interface (ISDN-BRI) connectivity to the
southern tier hospitals of Western New York. The project was to consist of
six regional hospitals namely, Soldiers and Sailors Hospital, Jones Memorial
Hospital, St. James Mercy Hospital, Ira Davenport Hospital, Schuyler Hospital
and URMC. The SMART project barely got off the ground but was replaced
by another telemedicine initiative.
proposal5 In June 1997, another was submitted to the committee
outlining a telemedicine project involving the New York State Department of
Corrections (NYSDOC). URMC was in a unique position to acquire
Jeannie L. Christensen Page 30 of 81 Capstone Thesis telemedicine technology via a contractual agreement with NYSDOC to
provide prison medical services. The telemedicine and video conferencing
will enable URMC to manage inmate medical care in Western New York. The
contractual agreement involves NYSDOC extending state pricing to URMC to
purchase telemedicine and videoconferencing equipment. It will provide a 16
percent cost savings versus URMC having to purchase their own equipment
(Appendix B).
Other goals for this telemedicine initiative were:
To link several potential regional hospitals for grand round presentations
(medical student sessions) and educational training. There is a high
degree of regional physicians who are very interested in linking with
URMC for Grand Rounds and other health related videoconferences or
training.
To provide clinical consults and patient triage - this implementation will
enable physicians from an equipment-advanced hospital to assist
physicians at rural or remote hospitals using medical video conferencing,
medical history and image transmission.
To enroll patients in clinical trials - some physicians feel that opportunities
exist to enroll regional patients in acute stroke protocols via telemedicine.
There are also interests in opening discussions around clinical protocol
enrollments.
Jeannie L. Christensen Page 31 of 81 Capstone Thesis To provide administrative conferencing - the telemedicine implementation
will provide cost benefits on several institutional collaboration.
The NYSDOC agreement for telemedicine application will strengthen
URMC's ability to build a coalition with other regional partners. Out of 26
surveyed regional institutions, 12 institutions indicated a presence of a
telemedicine application or pending grant. Below is a list of the 26 potential
regional partners:
Arnot-Ogden Immogene Bassett
Cooperstown Batavia VA Hospital
Jones Memorial Bath VA
Lakeside Memorial Canandaigua VA
Medina Memorial Cayuga Medical Center in
Ithaca Myers Community
Clifton Springs Newark-Wayne Community
Corning Nicholas Noyes Memorial
Cuba Memorial Olean General
F.F. Thompson St. James Mercy
Genesee Memorial St. Jerome's
Geneva General St. Joseph's
Ira Davenport Schuyler
Jeannie L. Christensen Page 32 of 81 Capstone Thesis Soldiers & Sailors Wyoming Community
The URMC and NYSDOC telemedicine project will also foster a more
personal relationships and acquaintances between healthcare professionals.
face-to- It will also impact patient referrals by enabling physicians to interact
face with their colleagues within the region without leaving the hospital.
In November of 1997, a Request for Proposal was sent out to other
medical departments in the hospital. Each department is welcome to submit
their telemedicine projects to the telemedicine committee. Several
departments responded to the RFP with promising projects of telemedicine
implementation from surgery to psychiatric applications (Appendix F).
The groundwork has been laid for the first telemedicine implementation
at Strong Memorial Hospital with hopes that the project will evolve to wider
use. With the aid of the growing telecommunications technology, and the
collaborative work with the NYSDOC, telemedicine will be on its way to
improve the quality of healthcare not only for the inmates but for the rest of
the region.
Jeannie L Christensen Page 33 of 81 Capstone Thesis TELEMEDICINE BACKGROUND AT THE NEW YORK STATE, DEPARTMENT OF CORRECTIONS
For many years the prison healthcare system has been using several
telemedicine applications. From a recent survey, 4 out of 10 most active
telemedicine initiatives were based on prison care. Again, for the prison
system telemedicine presents a strategic, cost-effective tool in delivering
healthcare to prison inmates. As more people are incarcerated for longer
periods of time, there has been an increase of demand in healthcare services
for inmates.
The University of Texas Medical Branch at Galveston and the Texas
Department of Criminal Justice jointly operates the second-most-active
telemedicine program in the United States. They logged 3,4000
patient/clinician interactions in 1 997 and more than 1 ,000 in the first quarter of
1 998. The third-most-active telemedicine program in the country is based in
Columbus, Ohio. The Ohio State University and the Department of
Corrections jointly runs the telemedicine project, logging 2,613 clinical
interactions in 1 997 and more that 750 in the first quarter of 1 998.
The New York State Department of Corrections also has a very active
telemedicine application. It delivers healthcare to over 70 correctional
facilities dispersed throughout the New York State. Many of these facilities
are in the rural areas, which requires medical, educational and legal services.
Jeannie L. Christensen Page 34 of 81 Capstone Thesis elow is a chart, provided by the NYS/DOC, which shows the current inmate
copulation and a projected population up to year 2001 .
80,000- 76,5 000 m ffOO 75,000 ri^^k 69^70^00
70,000 Wm^ &60 64i 65 ooo- ^f^S
60,000-K
55,000
50,000 ^-i jmm, ; ag IL_^r 1993 1994 1995 1996 1997 1998 1999 2000 2001
Table 1. DOCS INMATE POPULATION 1 997-2001 : Figures are projected 2000-20001: Applicable if capacity is approved by the Legislature
With such a projected inmate population, the demand for medical,
education and legal services also increases. Provisioning for video
conferencing the NYS/DOC can provide travel expense savings, time
savings, overtime expense savings, public and staff safety and also access to
otherwise unprovided services, i.e. staff training or regional seminars.
Currently, the NYS DOCs is responsible for health care of 70,000 inmates
held in 70 state correctional facilities. The DOC employs 1,400 primary care
staff and has approximately 1 Million primary care encounters per year. It
also encounters 69,000 specialty care cases.
Jeannie L. Christensen Page 35 ot 81 Capstone Thesis New York State's ^s^^Bare Hill'Chateaugay
" Ogdensburd ?rJLnnklJ,n; . correctional facilities Lvon \ Rivervlew \ M': Clinton/ Camp. \ A Gabriels--J---' !
_/X.
"Gouverneur,' Adirondack -T ..,'"-. Cape Vincent. \ 'Watertown } Morlahi
""" Washington Oneida ., '-,, Great Meadow
_ ' \y-~- Mohawk;-.. ""'--' '.Albion -Mid State -Mt; McGregor :. ..Ma Rochester. '--. - y.-HaleCreek lalo-Wende /---.- -- y-Auburn
'---/' wYmininGrovelanrt'' Camp Georgetown \ Cayuga "\ """CaiTip-Pharsalid. ., v Collins ^Livingston;--; ; Summit Lakeview-'Gowaoda '--. f "Cbxsackie/Greene ( ~"~" Monterey;. ",. / -. -, Hudson/ Elmiraj ; Southport
Woodb'ourne Eastern1 ^ullivan*. . Ulster too small to locate NShawangunk- . Wallkim Map BeaifonL"" "Green Haven \ ;-- NYC work release sites. S. "TFishkill/Downstate Otisville ._--/
- /[ Bayview Mid-Orangey- '."laconic Sino/t-"1/ Edgecombe Sing Bedford Hills Fulton Lincoln Parkside Queensboro/ ^rArthurKHI
FIGURE 1
Telemedicine increased the specialty care encounters. It reduced the
necessary trips that the inmate has to do to the regional hospitals to access
healthcare services, primarily emergency and specialty care consultation.
The NYSDOC implemented a seven-month period Telemedicine Pilot
project in 1995. The project started with emergency consult with 212 inmates
identified as patients appropriate for telemedicine screening.
The following results were collected during the pilot period:
Jeannie L. Christensen Page 36 of 81 Capstone Thesis 96 inmates were screened
28% of the inmates had needs met through telemedicine
36% went to the hospital and returned to the correctional facility
Admits" 35% were admitted to the hospital, many of which used "Direct to
reduce or eliminate waiting times
The telemedicine pilot also included specialty care consults with 46
recorded specialty care consults during the pilot period. Each consult
represented a trip saved to the hospital or specialty care clinic.
The telemedicine pilot also yielded five educational programs and four
administrative meetings. There was a total of 73 trips to different institutions
saved during the trial. Unfortunately, due to the varying length of each trip,
manual reporting instruments and the different inmate security classifications,
dollars saved was not calculated during the telemedicine pilot.
The NYSDOC had initially coordinated specialty care with four regional
healthcare institutions namely:
Western NY - Strong Memorial Hospital
Central NY - SUNY Health Sciences Center
Northeastern NY - Albany Medical Center
Lower Hudson - which is still to be named
Some of the identified services that the above-mentioned institutions will
provide includes medical triage of emergency patients, pre-admission testing
Jeannie L. Christensen Page 37 of 81 Capstone Thesis i.e., for Anesthesia, specialty evaluations such as dermatology and Infectious
Disease, and staff training. To date, the NYSDOC has academic and
medical partnership with several other institutions.
Figure 2 shows the actual map of the NYSDOC Telelmedicine Hubs:
NEW YORK STATE CORRECTIONAL FACILITIES
/rfS'r'r_2?TJ i-- l ./ .;>-~^v j f \---~Cf-13 4 ~ i_..rr..j. \i...vziru-->--> u i\ " V,--
NC TOWHOir HUB r-jPyg^J
FIGURE 2
telemedicine site. Each hub represents the areas covered by each
prison. It also Areas include maximum, medium, and minimum, security
and alcohol and included minimum security camps, mental health facilities,
centers. substance abuse correctional treatment
38 of 81 Capstone Thesis Jeannie L Christensen Page PROJECT DESCRIPTION AND METHODOLOGY
This telemedicine project gave the University of Rochester Medical
Center a unique opportunity to be involved with a well-recognized
telemedicine application. It will provide URMC the ability to build on strategic
alliances with the other hospitals and institutions within the region and
maintain our position as a leading tertiary institution in Upstate New York.
URMC has the potential to be the first Rochester hospital to establish a link
between 12 regional institutions that has an existing telemedicine technology
or grants with pending approval.
The telemedicine project will allow the hospital a means to provide
real-time medical consultations, view highly detailed images, enroll patients in
clinical trials, and conduct educational and administrative video conferencing.
It will also provide positive impact on patient referrals by allowing URMC
physicians to interact face-to-face with their regional colleagues without
leaving the hospital.
PARTICIPANTS
For this telemedicine implementation, the network project team
included technical staff from the University of Rochester Medical Center, New
York State Department of Corrections and Frontier Corp.
The following technical staff were involved with the planning and
implementation of this telemedicine project:
Jeannie L. Christensen Page 39 of 81 Capstone Thesis Jeannie L. Christensen - Senior Communications Analyst/Network
Engineer, Strong Memorial Hospital
John DeSocio - Telemedicine Coordinator, Media Center Strong Memorial
Hospital
Cathy Hoercher - Project Manager, University Telecommunications Division,
University of Rochester
Douglas Bentley- Senior Network Engineer, University Telecommunications
Division, University of Rochester
Mike Myers - Lead Network Engineer, Strong Memorial Hospital
Linda Powell - Telemedicine Coordinator, New York State of Corrections
Doug Miller Frontier Corp. Technician who was responsible for the T1
circuit provisioning, testing and diagnostics.
REQUIREMENTS AND SPECIFICATION
The main network design goal is to provide a high-speed
:elecommunication bandwidth between URMC and Albany NYSDOC Office.
site" The Albany site served as the "hub to the other correctional facility that
/ere part of the trial network., i.e., Albion Correctional Facility, Attica
Correctional Facility, Collins Correctional Facility, Groveland Correctional
"acility, or Wende Correctional Facility.
The NYSDOC contract required that the URMC network be operational with
services April 1 1 999. The project is challenged the ^e telemedicine by , by
Ch: ^nsen Page 40 of 81 Capstone . Jeannie L Thesis need to leverage our new ATM Backbone as well as the Internet connection
to deliver video, voice and data to the NYSDOC sites.
The requirements included purchasing two PictureTel Concorde 4500
units, which is in line with the equipment that NYSDOC uses in their
telemedicine sites. The preferred transmission system by the NYSDOC is a
point-to-point T1 circuit between the NYSDOC Albany office and URMC. This
is also what they have used on all of their other telemedicine sites.
COSTS
It has always been difficult to justify an experimental medical project.
In the telemedicine arena, cost was an important factor to consider. To fully
understand the actual cost to implement the project, the committee had to
break down the specific components necessary. Appendix A details the two
options for capital and operating costs. It shows the cost if NYSDOC were to
absorb some of the cost and if URMC shoulders all of the cost. There is a
noticeable difference on the rate for capital expenses due to the fact that
NYSDOC gets a much lower pricing from the PictureTel vendor.
The costs for the installation and circuit are comparable. Please note
that there is a minimal cost difference from the day the proposal was
submitted to when the final project was implemented. It affected the T1 circuit
call" recurring costs and the "per costs.
Since it's inception, emergency tele-consultations have been the focus
of the project therefore the Emergency Department will be one of the target
location for the PictureTel equipment. The emergency department needed to
C' JeannieL >: :.tensen Page 41 of 81 Capstone Thesis be equipped with a special room to house the equipment. It will also be used
for the clinical consultations. A room has been identified for this purpose but
it will have to be renovated.
call" Another cost issue is the "per cost. URMC will not incur any per-
call costs when conducting consultations, patient triage and educational
sessions as long as the call is initiated by the NYSDOC. Interaction with
call" other regional institutions will incur "per expenses, as follows (please
refer to Appendix A for the cost breakdown):
For two-party calls, URMC will dial the institution and will be billed a per
minute/channel cost. For example, if URMC dials Groveland Correctional
Facility, at $0.57 per minute/channel, a 15 minute call will cost URMC
$10.26.
A multi-way conference, which would be 3 institutions or more per call, will
be initiated by MCI. URMC will be charged for the per minute/channel
costs, the bridging costs, and the gateway service charges, if applicable.
Bridging costs applies if there are more than two parties in the
videoconference. Gateway service charges applied if the institutions in
the videoconference are not on the MCI dialing plan. A 60 minute three-
way call initiated by URMC will cost approximately $417.96
There was also a recurring cost for the T1 circuit, which included the
circuit maintenance and the access loop from the terminating central office
(CO) to the URMC main switch room at the Annex.
Jeannie L. Christensen Page 42 of 81 Capstone Thesis Other ancillary expenses included the training costs for two Media
Center personnel on how to use and support the video conferencing
equipment. These two Media center staff provided training, inservicing and is
currently the primary source for conference set-up. Below is a cost summary
projected for the first year inclusive of the start-up costs:
' ' ' '' ' . ; > - Initial Startup Cost ITEM NYS DOC Pricing Without NYSDOC Equipment $96,816 $114,800 Installation 2,940 2,940 Renovation 3,685 3685 Training 3,600 3,600 Total $107,041 $125,025 Projected Annual Opemating Costs Access Loop and $5040 Maintenance Regional Linkages $41,191 (consults and conferences) Total $46,231
FIGURE 3
Capstone Thesis Jeannie L. Christensen Page 43 of 81 IMPLEMENTATION
As mentioned before, since this is a telemedicine pilot project, the initial
goal is to provide emergency consultations. Therefore, one of the PictureTel
4500 units will be housed at Strong Memorial Hospital Emergency
Department with the main function of providing clinical consultations and for
patient triage of inmates and patients located in other regional institutions.
The original plan was to use the second unit as a roaming unit and will be
stationed in the third floor of the medical school at URMC. The location is at
the Media Center (Room 3-751 1 ). It was supposed to be used for four
strategically located conference rooms but it was not satisfactory for some of
the URMC departments. Due to staffing issues, some departments need
access to a roaming unit in some other locations closest to their area. It was
a unanimous decision to add several more potential rooms where the roaming
unit can be transported and connected to the network. It will be transported
to any of the following locations:
> Whipple Auditorium (2-6424)
> Class of 62 Auditorium (Medical Research Building)
> K-207 (2-6408)
> K-307 (3-6408)
> Upper and Lower S-Wing Auditorium (3-761 9)
> Ambulatory Care Facility Rooms A,B,C,D,E (2-1362)
Jeannie L. Christensen Page 44 of 81 Capstone Thesis > Ambulatory Care Facility Board Room (2-1322)
> Orbison Room (1-5421)
STANDARDS AND PROTOCOLS
The quality of compressed video varies depending on the specific
standard and bandwidth being used. The primary protocol for the voice and
video communication was another important factor that needed to be
resolved. The NYSDOC is using H.320 and which we ended up using at the
time the project was fully implemented. The H.320 protocol is a switched-
based protocol and it provided us with a point-to-point physical connection.
The H.323 protocol is packet-based and uses TCP/IP as its main transport
system therefore would have been able to coexist with our current ATM
backbone. The NYSDOC contract did not provide any flexibility on the
protocol that we can use.
Currently, we are still struggling to use H.323 and are running across
problems with the current equipment not being compliant to the newer
standard, which is discussed further on the next chapter.
We will not discuss these protocols in depth, but it is necessary to explain
why it was a standard protocol of choice and what other protocols or
standards are available for audio and video transmission.
The H.323 protocols, which are regulated by the International
"umbrella" Telecommunications Union (ITU), is an for a set of standards that
defines real-time multimedia communications for packet-based networks.
Jeannie L. Christensen Page 45 of 81 Capstone Thesis Much of the excitement surrounding H.323 protocols involves their enabling
H.323 entities to communicate over the Internet or managed Internet Protocol
(IP) networks. The standards under the H.323 umbrella define how
components that are built in compliance with H.323 can set up calls,
exchange compressed audio and/or video, participate in conferences, and
interoperate with non-H.323 endpoints.
The H.320 recommendation governs the basic video-telephony
concepts of audio, video and graphical communications. It specifies the
requirements for processing audio and video information. It also provides
common formats for compatible audio/video inputs and outputs and protocols
that allow a multimedia terminal to utilize the communications links and
synchronization of audio and video signals.
This recommendation specifies technical requirements for narrow-band
visual telephone systems and terminal equipment, typically for video -
conferencing and videophone services. It describes a generic system
configuration consisting of a number of elements which are specified by
respective International Telecommunications Union (ITU) recommendations.
Such elements included the definition of the communication modes and
terminal types, call control arrangements, terminal aspects and
internetworking requirements. Some of the revisions to this recommendation
are reflected in relevant H-Series recommendations such as H.262, H.263,
H.310, H.322, H.323 and H.324. Below is a list of the Multimedia
12 Teleconferencing Standards Recommendations in force today:
Capstone Jeannie L. Christensen Page 46 of 81 Thesis Video - These standards specify methods of video compression and communication.
? H.320 - Narrow-band Visual Telephone Systems and Terminal Equipment.
ISDN (Integrated Services Digital Network) video conferencing
? H.323 - LAN based video conferencing
? H.324 - POTS (Plain Old Telephone Service) modem based video
conferencing
? H.221 - Frame Structure for a 64 to 1920 kbit/s Channel in Audiovisual
Teleservices
a H.261 - Video Codecs For Audiovisual Services at Px64 Kbps HTML
q H.230 - Frame-synchronous Control and Indication Signals for Audiovisual
Systems
? H.231 - Multipoint Control Unit for Audiovisual Systems Using Digital
channels up to 2 Mbit/s
a H.243 - System for Establishing Communication Between Three or More
Audiovisual Terminals Using Digital Channels up to 2 Mbit/s
Audio - These standards specify methods of compression and
communication for the sound contained in a video conference.
a G.711 - Pulse Code Modulation (PCM) of Voice Frequencies; provides
telephone quality audio (narrow band, 3.4 kHz)
Jeannie L. Christensen Page 47 of 81 Capstone Thesis 3 G.722 - wide band, 7 kHz Audio-coding Within 64 kbit/s; provides stereo
quality audio
3 G.723 - Algorithm for compressed digital audio over POTS lines. It is
used with H.324.
3 G.728 - Coding of Speech at 1 6 kbit/s Using Low-delay Code Excited
Linear Prediction; provides audio for low bandwidth calls (16 kbps)
j G.729 - Voice algorithm (CS-ACELP: Conjugate Structure Algebraic Code
Excited Linear Predictive) for coding speech signals in
telecommunications networks
It is unfortunate that we were not able to leverage the current network for
our telemedicine implementation. We have hopes that within a year or two
the migration to H.323 would happen. Like the other multimedia
teleconferencing standards, H.320 can be applied to multi-point and point-to-
point sessions over circuit switched services like ISDN or Switched-56.
Jeannie L. Christensen Page 48 of 81 Capstone Thesis NETWORK DESIGN
After several committee meetings, the team divided the
NYSDOC/URMC project into two phases. This way it would be easier to
implement and monitor the task on hand.
Phase 1 will touch upon the network design which included procuring
the T1 circuit, determining the demarcation line, extending the circuit to the
URMC Media Center Studio, planning for horizontal wiring for the Emergency
room and individual conference rooms. Renovation of the emergency room
was also ongoing during this phase.
Phase 2 will focus on the deployment of the telemedicine equipment,
provisioning the T1 circuit and doing some testing. Phase 2 also included the
administrative team's activities. In order to develop linkages with the regional
hospitals there will be a team that will visit each institution and conduct a
demo on linking with URMC for conferencing and consultations. Additionally,
the team will also consider other post implementation issues such as overall
of the telemedicine cost (inclusive of the recurring expenses) and usability
project.
PHASE 1 :
of an network We started with Phase 1 by doing a site survey existing
facilities. Linda NYSDOC in one of the New York State correctional Powell,
Correctional Attica New York because of its coordinator, chose Attica Facility,
of 81 Capstone Thesis Jeannie L. Christensen Page 49 . location and that it has an extensive telemedicine network implemented. I
went alone and met Linda Powell at a nearby hotel. That was my first time
inside a correctional facility and didn't know what to expect. Upon entering
the facility, it was necessary to go through heavy security check. It was very
organized and systematic. I was led to the Administrative Offices where they
house their telemedicine equipment.
One of the smaller rooms contained the facility's network devices. I
learned that their normal setup would consist of a T1 line terminated into a
Channel Service Unit/Data Service Unit (CSU/DSU) and then to a Cisco
router. There is also a modem connected to the router for remote diagnostics
and maintenance. They are using Category 5 unshielded twisted pair cable
for the room wiring.
During the visit, an actual video conference call was made to Albany to
discuss the some of the other details we will need for the URMC network
design. I was able to observe a demonstration on how some of the
telemedicine equipment will be used for an actual patient consultation and the
transmission. Some of the telemedicine clarity of both video and voice
otoscope peripherals included a forms document reader, an x-ray reader, (for
dermascope (for the skin). For this le ears), ophthalmoscope (for the eyes),
document reader. (Refer to elemedicine application, we purchased an ELMO
- opendix A for the Budget Proposal.)
50 of 81 Capstone Thesis Jeannie LChn risen P*Sg Photo 2: Linda Powell in an actual video conference from Albany, New York. The picture-in-picture is the URMC side.
A key component that was relevant to our network design was network
fault tolerance. Our intent was to offer connectivity with very minimal or no
downtime and define a protocol for maintenance and support of the network.
Our goal was to connect the NYSDOC to the URMC network via a wide
area network and connect it to the hospital's local area network, providing
voice, video and data service, with relatively high level of support and quality
of service.
The NYSDOC has an exis^ng contract agreement or dialing plan with MCI
for their circuits. It was to URMC's advantage if we use the same service
provider. All administrative and maintenance support would be through MCI
although part of the wide-arec network's physical layer used Frontier Corp.
Jeannie L. Christensen Page 51 of 81 Capstone Thesis and Time Warner Communications. Our decision to procure a T1 circuit from
these service providers was pre-determined by the NYSDOC contract with
the vendor. The T1 circuit provided the bandwidth of 1.544 megabit T-carrier
channel that can handle 24 voice or data channels at 64 Kbits/sec. A
standard T1 frame is 193 bits long, which can hold 24, 8-bit voice samples
and one synchronization bit. It would be transmitting 8,000 frames per
second. Six channels were dedicated for NYSDOC use, and another six
channels was earmarked for video conferencing. There will be 12 idle
channels that will be used for scalability. It will be available for use in the
event that URMC decides to purchase additional video conferencing systems.
The T1 line is originating from an MCI LEC and will co-locate with the
central office for Time Warner and Frontier Corp at Fields Street (Figure 4).
The demarcation line will be at the main switch room at the Medical Center
Annex located at Elmwood Avenue.
of 81 Capstone Thesis Jeannie L. Christensen Page 52 FIGURE 4: Wide-Area Network Topology
Figure 4 illustrates the building-to-building physical wiring for the
telemedicine project. It shows how we extended the T1 line from the provider
demarcation line to the customer premise's termination line.
Previous to this project, a multi-mode fiber connection was installed
from the Media Center Studio to the Medical Center Annex. It was originally
allocated for a telemedicine initiative that did not materialize. Photo 3 shows
the logical interface unit (LIU) that is in the Media Center Studio. For this
project we used two fiber strands to extend the T1 line from the Medical
Center Annex to the Media Center Studio location utilizing a copper repeater
n between as a signal booster.
Jeannie L. Ch -ansen Page 53 of 81 Capstone Thesis - 0 <& ^ O > *g dl
Photo 3: Top devices are the 2 Ascend RPMs and one Ascend Multiplexer; bottom device is the Fiber Logical Interface Unit. All equipment are located in the Media Center Studio (Room 3-7511).
circuit had to The equipment used for the termination of the T1 comply
requirement. We had to use the Ascend with the NYSDOC's equipment
Port Module Multiplexer (IMUX) and the Ascend Multiband Remote (RPM)
compatible with the NYSDOC. The RPM is since it was widely used and are
booster. essentially another signal
in depth on the It is beyond the scope of this project to go proprietary
short definition of the devices is necessary. equipment but I do believe that a
Pacie 54 of 81 Capstone Thesi Jeannie L. Christensen The Multiband VSX T1 is a compact, scalable inverse multiplexer that
can establish group or desktop videoconferences at speeds ranging from 112
Kbps up to a full T1 (1 .55 Mbps) and can be expanded to handle
simultaneous voice and video traffic over the same T1 line. It optimizes dial-
up bandwidth and came with a built-in CSU/DSU which eliminates the need
for a stand-alone unit. It could also be configured either locally via a console
port or remotely for easy diagnostics and management.
The Multiband RPM is a self-contained port extension device that
allows the Ascend IMUX to communicate over regular copper wire and the
existing data jacks instead of running special wiring. It extends the
functionality of the IMUX up to 3,400 feet. The Ascend IMUX acted as a
CSU/DSU as well.
We needed four RPMS: two RPM's was located at the Media Center
Studio, the would act as the receiver for the other remote RPMs. The third
RPM will be with the PictureTel unit at the Emergency Department, and the
last RPM will go with the roaming PictureTel unit. We connected the T1 line
to the CSU/DSU in the Media Center Studio that was a built-in component of
the Ascend IMUX. It came equipped with RJ-45 ports to accommodate 4
Fiber-to- RPMs. Photo 4 shows the Ascend IMUX and the RPMs. We used a
RJ45 transceiver to connect the Ascend IMUX to the Fiber LIU. Photo 4
Ascend IMUX. shows the final termination of the T1 line to the
of 81 Capstone Thesis Jeannie L. Christensen Page 55 Photo 4: Back of Ascend IMUX (bottom) and the Ascend RPM's (top)
We now come to the physical wiring for the room location. As
previously mentioned, there were two main locations for the 2 PictureTel Unit,
one in the Emergency Department, and the other would be used as a roamer
for different conference rooms (Figure 5). From the Media Center Studio
location we ran Category 5, unshielded-twisted pair cables to the identified
conference rooms and one to the Emergency room. The RPM's provided us
with 3,400 feet limit for our Category 5 cables. The Cat5 cables will be
terminated in different computer equipment rooms (CERs).
Jeannie L. Christensen Page 56 ot 81 -.aostone Thesis FIGURE 5 Pulled several Category 5 (gray) cables from 3-8528 to the different Computer Equipment Rooms (CERs). Below is the cable path all over the hospital.
MEDICAL CENTER STUDIO (3-8528)
(5) CAT5 CER G-1289 CER B3 (3-7508) Emergency Rm (1) CAT5 to a new 66 B lock Panel Labeled PICTEL
V^M ' -:,-^-"x > CER B2 (2-7508) CAT5 \;---; (4) \ CER P2 Am bulatory CER F2 (2-6440A) Care Facility \ \ M
CER F1 (1-6438) NOTES:
Approximately, 9,500 feet of Category 5 (gray) cables was used for the individual room wiring.
V CER M1 (1-3452)
' to a new 66 Block Panel Labeled PICTEL "V-':f--V : !. \
Figure 5 illustrates the physical cabling run from CER-to-CER location.
All of the above-mentioned conference rooms and auditoriums needed
(CER). we physical wiring to the nearest computer equipment room Again,
cannot exceed our 3,000 feet limit with the Repeater Port Module (RPM)
different to the nearest therefore it was necessary to shorten the cable run to
CER. Each cable wiring was tested and certified by the University
Telecommunications Division.
of 81 Capstone Thesis Jeannie L. Christensen Page 57 G- ED Medlcme (ROOM # CONFERENCE ROOMS 1339) Whipple Aud. (2-6424) K-207 (2-6408) PtcWeTel K-307 Roamer F ctureTel (3-6408) Orbison Rm (1-5421) Unit Unit Upper/Lower S-Wing (1-7619) (50 ft Max) (50 ft. Max) ACF Conference Rm (2-1362) AB,QD,E -A ACF Board Room ^PM M
i Cat 5/RJ45 Cat 57RJ45 Q-j (3,000 ft. PATCH PANEL (3,000 ft Max) i^n Max)
RPM RPM NOTES:
T1 line will provide 24 channels. MUX has 4 ports for RPMs.
Ascend IMUX
6 channels per video Unit
Medical FIBER Center T1 Line MCI T1 ANNEX CSU/DSU Line (Demarc) Provider
Media Center Studio
FIGURE 6: URMC Telemedicine Network Topology
auditoriums will All of the above-mentioned conference rooms and
equipment room (CER). Figure need physical wiring to the nearest computer
implemented. 6 illustrated how the overall network would be
complicated the distance from The initial network design was further by
the Care the individual conference rooms, particularly Ambulatory Facility
58 of 81 Capstone Thesis Jeannie L. Christensen Page and (ACF), the URMC Media Center Studio. There are five conference
rooms in the ACF that needs Cat5 wiring to access the PictureTel IMUX.
There were three design options that was considered:
1 ) Run a Cat5 cable from the Media Center Studio to the CER B2 and
from there use existing fiber cables to the ACF building CER. This
design needed some fiber to copper repeaters along the path which
raised the implementation cost.
2) Run Cat 5 cables from the Media Center Studio to CER M1. From
there we can daisy chain each conference rooms. This design
exceeded the limitation of 3400 feet.
3) Use a start topology and home run each conference rooms to the
closest CER. The individual conference rooms were then wired to
nearest individual CER.
We decided to go for option 3 because of the cable length limit. We
wanted to keep the wiring cost at a minimum. We used 9,500 ft of Cat5 cable
and the total cost was approximately $7,000 (inclusive of labor) and was
within the budget.
It took over a month to procure the T1 line and less than two weeks to
finish the cabling.
Jeannie L Christensen Page 59 of 81 Capstone Thesis I
PHOTO 5
Photo 5 shows the punch block we used for the Category 5 room-to-
room wiring. The one on the left is computer equipment room (CER) in ED
and on the right is CER M1.
J_eannie L. Christensen Page 60 or 81 Capstone Thesis PHASE 2:
While Phase 1 was ongoing, John Desocio and I were also busy
training ourselves on how to use the PictureTel units. Mr. DeSocio went for
the PictureTel training, as planned. There was a budget for it and he was the
one that will be mostly interacting with the system as soon as we have the
telemedicine application successfully implemented.
As soon as we had the T1 line extended to the Medical Center Media
Center Studio, we began installing the Ascend equipment. This was when we
discovered that the Ascend IMUX was the wrong component because it did
not come with the correct number of ports. We had to have one shipped to us
in relatively short time. Upon delivery of the correct Ascend IMUX, John
Desocio and I used the recommended test transmission by the vendor and
were successful. The T1 line was terminated by Frontier instead of MCI. A
local Frontier technician assisted us during the line test.
We had to wait until after the T1 circuit has been provisioned before we
could configure the PictureTel unit with the proper circuit channel numbers
(almost like a local phone number to dial).
There were two parties involved with the final testing phase. The near
would be the end, located at the URMC and the far end, which Albany
NYSDOC Administrative office. Even if we have two location with two
unit. PictureTel unit, both will be consider the near end
Capstone Thesis Jeannie L. Christensen Page 61 of 81 Photo 6: The team started provisioning the line with the assistance of Doug Miller, Frontier Corp. technician.
We then proceeded with the T1 circuit testing. We ran across a
problem on the transmission test but found out that the circuit was
unknowingly left on diagnostic purpose on the vendor side. It took one
phone call to the service provider to remedy the situation. The T1 line was
configures as follows:
No. of Channels per video unit: 6 channels, with total 12 channels for the 2
video device we purchase. One for the ED room and one to function as a
remote unit.
Channel 1-6 was given a local number of #3021400
Channel 7-12 was given a local number of #3031400
Jeannie L. Christensen Page 62 of 81 Capstone Th6S!S Channel 13 -18 idle
Channel 19 -24 idle
Signaling Mode: Inband
Framing Mode: D4
Line Encoding: AMI, standard loop
Facilities Data Link (FDL): None
Rob CM: Idle Start/No wink
It took us a day to provision the line and we decided to postpone the
actual transmission to Albany until the next day.
Photo 7: John Desocio with the actual telemedicine PictureTel Unit at the Emergency Room at URMC
Caostone Jeannie L Christensen Paae63of 81 Thesis With the T1 circuit properly configured and tested, John Desocio was
able to configure the PictureTel Unit with the actual channel numbers. We
tried to connect to the NYSDOC Albany office to do our first video conference
but was unsuccessful. We encountered two problems.
we had a First, noticeable latency problem. The video and audio
transmission was not quite synchronized. After further test on the circuit, we
discovered that we had a bit error rate failure.
Second problem was the frequent disconnection. We ended up
changing some of the PictureTel unit's configuration and mirrored the
configuration that the far end unit was using. We did several more test
session with Albany after fixing all of the configuration problems.
After our successful sessions with the NYSDOC office in Albany, we
then requested for Jones Memorial Hospital to participate in an actual video
conferencing with us.
The test was again successful and we proceeded with setting-up the
second PictureTel unit as a roaming unit and applied the same test
procedures we did with the ED unit. There were a couple of rooms wherein
ve could not get a successful transmission. Even if it passed the test, it
urned out that we had a cross-wiring in one of the conference rooms and the
econd was damaged due to a recent renovation.
Jeannie L C\ ^nsen Page 64 of 81 Capstone Thesis DISCUSSIONS, OUTCOMES, MEASUREMENTS
Although my primary role was to design the wide and local area
network for the URMC telemedicine project, I was also exposed to the other
issues involving the implementation, i.e., the logistics of providing medical
diagnosis, billing issues and other administrative overhead. I attended some
meetings where the following issues where also discussed aside from
network connectivity:
> Because it is not a routine medical consultation by the emergency room
billing by physicians for services will also be different. The general billing
codes will sometimes not apply on the telemedicine consultation. A new
billing structure was developed to accommodate these issues.
> We have to determine the logistics on filling up patient forms that would be
necessary for the consult, such as consent forms, assessment forms and
referral forms.
> Physicians will have to be available in both the near and far end.
> Video taping the patient session has always been available. There should
be a presence of a document camera, medical peripheral camera and the
external camera. This also touched upon patient confidentiality.
A key feature of telemed' :^ne systems, which distinguishes them from
peripheral devices. These simple videoconferencing sy aims, is the use of
of an on-site physical enable the clinician to have z better approximation
of standard examination examination. This will indue electronic versions
Capstone Jeannie L Christensen Page 65 of 81 Thesis tools (stethoscopes, otoscopes, ophthalmoscopes) as well as other 'sense
extending' implements are close- that almost exclusively electronic, such as
up cameras and document stands, dermascopes, and microscopes. These
are the tools that might be most useful in a multi-specialty telemedicine
practice. There is a wide range of electronic tools specific to various
13 specialties like cardiology, dermatology, ophthalmology, and radiology.
Such tools were not available when we first tested the telemedicine project
and further assessment of the need for particular tools had to be done.
The lack of billing structure was quite a concern. This issue took
several months to resolve due to its legal and political implications. The
NYSDOC has a contract with the Center for Disease Control Prevention
(CDC) for it's administrative and billing procedures. Although there was a
structure that could have been adopted, certain issues had to be considered
such as specialty consult fees and referral fees.
Upon finishing the NYSDOC/URMC telemedicine project, I had very
little interaction with the telemedicine team. I decided to seek some results
and usability information for this project. I recently had the pleasure of
discussing the current telemedicine application with Dr. Mary Gale Mercurio,
Chief Physician for the Department of Dermatology at Strong Memorial
Hospital. Mr. John DeSocio, who is now the Director for the Telemedicine
present the interview. Initiatives at Strong Memorial Hospital, was also during
on how the Department of They were able to provide me with some insight
Dermatology uses the telemedicine application.
Capstone Jeannie L. Christensen Page 66 of 81 Thesis Dr. uses Mercurio the PictureTel and other telemedicine equipment
that are part of the initially implementation. She has patient consultation at
least three times a week. She manages to see inmates for approximately 12
hours per week with a minimum of an hour per inmate session. It is
estimated that she averages 45 to 48 patient sessions per month. From the
previous chapter, we have determined that the average cost savings for a
telemedicine application could be at least $157.00 per session (refer to
section on reduced cost). This equates to a cost savings of $7,536.00 per
month or $90,432.00 per year. This cost savings is for the Department of
Dermatology alone and does not include other departments such as the
Emergency Room consultation.
I also asked Dr. Mercurio if there has been an instance where the
telemedicine session did not workout for her. She said that every one of her
patient sessions were successful except for one patient. The inmate was
"short-changed" happy with the treatment but that he felt he was possibly due
to the fact that the inmate was not able to travel outside of the prison.
When asked about the diagnostic accuracy and medical procedures,
she said that it's just as if the patient was there, except that she really can't do
the actual procedures. After offering the diagnosis, she relies on the far end
medical staff to provide the necessary treatment. She provides medical
diagnosis and the necessary prescription drug, if necessary.
Dr. Mercurio has to rely on the assistance of John DeSocio for setting
peripherals the consultations. up and assisting her with the medical during
Jeannie L. Christensen Page 67 of 81 Capstone Thesis According to Mr. DeSocio, technical assistance is a matter of personal
preference. Some physicians prefer that he sets up the consultation and walk
out of the room. In Dr. Mercurio's case, she doesn't mind his presence and
the patients are made aware of this.
Not every correctional facility is outfitted with the best telemedicine
equipment. Some institutions do not have digital cameras therefore the
image resolution is not as good. Dr. Mercurio was able to make headway by
utilizing some light device, such as a built-in light on the camera, a lamp or
flashlight.
After discussing the URMC telemedicine project with Dr. Mercurio, I
can safely say the there is a great need for compilation or a study on the
clinical outcomes and cost-benefits for every telemedicine implementation.
There is also a need to have a primary repository for these studies, readily
accessible to medical staff or even students. Documentation of the benefits
of telemedicine can help with future request for funding requirement, medical
research, and other issues that a regular medical consult would have.
Based on this interview, it is obvious that Dr. Mercurio has a large
need for the telemedicine project. For the physician, telemedicine extends
normal reach. For the it their ability to care for people beyond their patient,
will not fall into neglect. Dr. offers them the specialty care they need and
Mercurio's successful use of the telemedicine application has a big impact on
the initial cost for the medical community at Strong Memorial. Barring
Capstone Jeannie L. Christensen Page 68 of 81 Thesis implementation, it is a good example of how medicine can leverage
information technology,
Jeannie L. Christensen Page 69 of 81 Capstone Thesis TELEMEDICINE FUTURE/DIRECTION AT THE UNIVERSITY OF ROCHESTER STRONG MEMORIAL HOSPITAL
The future of telemedicine at Strong Memorial Hospital looks very
optimistic especially after the local area network went through a most awaited
overhaul. Two and half years ago, Strong Memorial Hospital invested over $2
Million dollars to upgrade its existing Legacy backbone to one of the most
advanced Fiber optic backbone within the University of Rochester and called
it the Enterprise Network. The physical layer of the Legacy backbone
comprises of many thick coax cabling that terminates to a singular router.
There were approximately 28 subnets within the hospital network that made it
very difficult to find a convergence point for a telemedicine application. The
enterprise network's physical layer is all fiber optic and uses Asynchronous
Transport system (ATM) as its main transmission system.
The URMC Telemedicine team was able to leverage this new
technology for the implementation of the NYSDOC project. We had to run
new cables for the conference rooms that are not properly wired to the legacy
network.
Today, the NYSDOC project is closely linked to the ATM core
backbone and had a major impact on the state of the telemedicine network,
as shown on this diagram of the new Strong Health Videoconference
Telemedicine Network (Appendix C).
Jeannie L. Christensen Page 70 of 81 Capstone Thesis Aside from the network overhaul, the Telemedicine group at Strong
Memorial Hospital had gotten the recognition that it deserves. It now has
complete administrative support staff and a stable funding. Several
departments at the hospital are also leveraging the telemedicine network.
Appendix C presents the new telemedicine infrastructure at Strong Memorial
Hospital.
The Ascend Multiband is connected via a PRI to the new Madge Model
60 call gateway. This gateway is capable of receiving up to 52 calls. The
Madge gateway is connected to another H.320/H.323 gateway to the URMC
local area network. The Madge is also connected to the PSTN cloud via a
PRI which connects to ISDN leased lines to six offsite location.
There are other telemedicine initiatives within the hospital. The
Department of Pediatrics submitted four telemedicine proposal in November
of 1997. ED had one proposal for a telemedicine application. The
Department of Dermatology and Poison Control has been approved. The
Department of Radiology has implemented a clinical archiving system at the
hospital that makes the x-rays available for remote viewing. There are
several video conferencing applications using the current telemedicine
infrastructure. As of the writing of this paper, there is no accurate data on
what telemedicine application has been approved. Appendix B is a short list
1997. of the Request for Proposals that was sent out in November of Several
Hospital. of these proposals are now running at Strong Memorial
Jeannie L Christensen Page 71 of 81 Capstone Thesis Telemedicine and the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Information technology has a definite role in today's healthcare industry
and offers many potential benefits. With the availability of electronic medical
records, hospitals can now offer a way of providing cost-effective access to
more complete and accurate health data with which providers can make
care.15 better decisions about patient The sharing of patient information is
intensified by the presence of advanced communications networks that
enables sharing of data across distributed clinical systems.
Patient privacy has increasingly become more complicated especially with
the presence of advance information technology. Use of information could be
acceptable for some instances but can be considered invasion of privacy for
others. Different areas of information privacy raise very different concerns
and priorities. They also require different types of expertise to address them
in a meaningful manner. The agencies currently involved with privacy issues,
such as the National Coalition for Patient Rights and the National Information
Infrastructure (Nil), are dealing with specific areas of privacy that these
agencies are uniquely qualified to handle {e.g. privacy issues arising in
consumer transactions, in telecommunications, in law enforcement, in
16 government records, etc.).
In the United States, business and government have adopted sector-
specific privacy rules, combining legislation, regulation, and voluntary codes
to achieve the desired level of privacy protection in each sector. Each of
Jeannie L. Christensen Page 72 of 81 Capstone Thesis these set of rules offers a different level of protection, and provides a different
remedy. There already exist privacy laws that apply to patients in general.
Such laws includes:
The right of patients to determine what information in their medical
records is shared with other providers or other institutions and
agencies
The right of the patient to know any disclosure of medical records
outside the context of clinical care and should require the consent of
the patient
Or, the patient's legal right to review and copy their medical records.
The healthcare industry as a whole is facing financial pressures to
reduce expenses and increase efficiency. The Hospital Insurance Portability
and Accountability Act of 1996 (HIPAA) is hard at work to address these
issues. Through government regulations, HIPAA promotes the greater use of
electronic transactions and the elimination of inefficient paper forms. The
regulations are expected to provide a net savings to the health care industry
of $29.9 billion over 10 years, according to government calculations.
HIPAA is a comprehensive law that will drive the development of
electronic data interchange (EDI) for specified administrative and financial
healthcare transactions. Most of the healthcare institutions are now
capitalizing on Internet technologies to deliver patient-related services and
they must now comply with HIPAA regulations.
Jeannie L. Christensen Page 73 of 81 Capstone Thesis One objective of HIPAA (defined under Administrative Simplification) is
the requirement for Congress to legislate a Patient Privacy Bill that will define
rules for the protection of Patient Information. These rules will be applied
through the security standards, policies, and practices that all entities must
implement if they are to use, store, maintain, or transmit patient health
information. Specifically, healthcare providers, payers, clearinghouses, billing
agents, third-party administrators, will soon be affected by the requirements of
administrative simplification and patient privacy. Again, this will affect any
telemedicine applications because it's underlying objective is to provide
medical services using remote access.
Jeannie L Christensen Page 74 of 81 Capstone Thesis SUMMARY
Medicine at a distance is one of the most basic definitions of
telemedicine. The practice may rely on satellite or ordinary telephone lines or
facsimile.1 it may involve television or Whatever the level of technological
advancement, the same goal exist - to improve access to medical expertise.
Throughout the world, Dr. Ken Bird and Dr. Max House inspired health care
professionals closer to each other. It is by implementing a telemedicine
and/or video conferencing technology that the hospital institutions can create
a system by which they can service the needs of the local, regional, national,
and even international communities. It readily provides an effective means
for visual communication and collaboration and supports many of the
healthcare institutions core activities. Telemedicine services also provides a
good opportunity to engage in consultation and education in places beyond
the traditional health care market, i.e. accessing new patient populations,
sites for new research, and new venues for the exchange of educational
consultation" programs. It can provide "second opinion wherein third world
countries can consult with a more medically advanced like the United States.
To actually understand the passion and devotion of these physicians to
the cause of telemedicine, I had to really read up on the many benefits it had
provided. The applications it offers if unbelievable and definitely futuristic.
According to the Association of Telehealth Service Providers in Portland,
Oregon, the number of telemedicine consults has grown by 24% just in 1998
Jeannie L. Christensen Page 75 of 81 Capstone Thesis alone. In 1998, there were 52,000 telemedicine consultations, both
physician-to-patient and physician-to-physician interactions. This is up by
10,000 from 1997. The 1999 figures are expected to be 74,000, which is an
17 increase of 42% from year 1998.
The most active clinical areas for telemedicine applications are
dermatology, cardiology, orthopedics, neurology, and mental health. In the
United alone, there are about 170 telemedicine initiatives.
The project itself offered me a hands-on experience on implementing
technology but my research work has offered the most benefit. Considering
that it was a relatively small project compared to other enterprise network
implementation, it still had a major impact on the people's lives it touches,
especially mine. We always say that technology changes everyday. This
project gave me a chance to experience how it changes people's lives. It
may not change my life at this very moment but I am sure that somehow
telemedicine will soon touch my life and my children's lives. I am convinced
that telemedicine is changing the dynamics of how health care is moving.
Jeannie L. Christensen Page 76 of 81 Capstone Thesis APPENDIX A
Telemedicine/Video Conferencing Budget Proposal
NYSDOC/URMC URMC |l EMERGENCY DEPARTMENT Capital Costs Base System Concorde 4500, l-Mux, Installation & first $40,980.00 $47,950.00 year warranty Remote Port Module $2,412.00 $2,850.00 ATR Receive Ausculette Stethoscope (DOC provided) (DOC provided) 30 Frames/sec. $6,201.00 $6,680.00 TOTAL $49,593.00 $60,380.00 VIDEO CONFERENCING j Capital Costs Base System Concorde 4500, Installation & first year $33,496.00 $39,190.00 warranty Remote Port Module $2,412.00 $2,850.00 30 Frames/second $6,201.00 $6,680.00 ELMO Document Camera $5,114.00 $5,700.00 TOTAL $47,223.00 $54,420.00 INSTALLATION COSTS
MCI T1 Circuit No Charge No Charge T1 Extension to Med Center Media Center Studio $150.00 $150.00 Cat 5 Lines from Media Studio to ED & Conference Rms $2,790.00 $2,790.00 TOTAL $2,940.00 $2,940.00 RECURRING COSTS | T1, Access Loop (from Annex to MCI office electronics $416.20/mo. $416.20/mo. Circuit Maintenance $3.84/mo. $3.84/mo TOTAL $419.96/mo. $419.96/mo. MISC. EXPENSES l
Renovation of ED Medicine Room $3,534.53 $3,534.53 Telephone Installation $150.00 $150.00 Training Costs for 2 Media Personnel $3,600.00 $3,600.00 TOTAL $7,284.53 $7,284.53
PER CALL COSTS
Instate (standard call 6 channels) $ .57/min/channel $ .57/min/channel
Out of State calls $ .06/min $ .06/min.
Bridginq Services (3 parties or more) $ .98/site/min $ .98/site/min Gateway Services (needed if parties are not on the $1.00/min $1.00/min same MCI Dialing plan
Jeannie L. Christensen Page 77 of 81 Capstone Thesis APPENDIX B
Summation of Proposed Telemedicine Projects
This list is just a partial list of the Request for Proposals (RFPs) done in December of 1997. Most all of the medical department at Strong Memorial Hospital submitted their proposals which included, project description and rationale, desired outcomes, support for institutional goals, participants, support services needed, source of external funding and the expected costs. As of the writing of this paper, there is no available source for the overall outcome of this request for proposals.
Department/Purpose Description Dept. of Physical Medicine Computer-based video teleconferencing can provide a vital link and Rehabilitation - for between the SCI program at Strong Memorial Hospital and the Spinal Cord Injury (SCI) patient, either in their home or in a satellite facility. The pain patients involves the use of a portable teleconferencing system that would interface with the spine team over the Internet. Initially, the equipment would be kept at SMH and transported to the patients home as needed, or to a satellite facility for quarterly SCI outreach clinics. The SCI nurse liaison would be instructed in the use of the equipment and would transport and operate it.
Remote interpretation of X- The main project goal is to increase the physician referral base Rays to expand Strong and provide timely and cost effective radiological services to Health's Out-Reach both patients and physicians in sites within the Strong Health Program service area. Early Detection and This proposal describes the opportunity to develop and deliver a Management of Mental first step in a disease management approach for depression, Health Problems in Primary integrating mental health services with primary care. The Care Settings: A primary care physician typically sees most mental health Telemedicine Application for problems. Integrating accessible, rapid mental health services Depression within primary care services can lead to more effective office- based treatment for mental health problems.
Department of Pediatrics The Continuing Medical Education Program of the Department Continuing Medical of Pediatrics holds a meets every month for informal discussions Education Program via that counts towards CME credits. There are about 35 - 50 Telemedicine pediatricians and family medicine practitioners and attracts participants from the entire 15 county region in Western New York. The CME videoconferencing will allow for an expanded audience and more efficient use of time for actively participating physicians since there would be no need for prolonged travel to Rochester, especially in the wintertime.
Jeannie L. Christensen Page 78 of 81 Capstone Thesis Department/Purpose Description
Department of Radiology The department would like to leverage the existing telemedicine network to support off-site locations in providing clinical consultation. It will become more feasible for a radiologist to cover an off site location and as an expert system will obviate the requirement of an on-site radiologist to answer the majority of routinely asked questions concerning the imaging evaluation of patients. OB/GYN Psychiatry The OB/YN Department of Psychiatry would like to use the telemedicine network to provide remote diagnosis to women of childbearing age who would potentially be suffering from depressions. Psychiatric problems commonly develop in women of childbearing age. These reproductive years are the time of greatest risk for the development of depression and the lifetime
prevalence of depression in females to males is 2:1 . The goal to have early detection of depression. Comprehensive Epilepsy The CEP of Strong Memorial Hospital is a regional referral Program (CEP) and the center for the diagnosis and management of intractable seizure Neurophysiology Division disorders. The Neurology Division at SMH provides interpretation and consultation services for inpatient, outpatient, and intra-operative electroencephalograph (EEG) and evoked potential Epilepsy Program studies. The in future the division hopes to provide studies to a number of external sites through a wide area network. There is a desire to expand the EEG and EP interpretation and consultation markets, such as the VA hospitals.
Jeannie L. Christensen Page 79 of 81 Capstone Thesis APPENDIX C University of Rochester Strong Memorial Hospital Newly Upgraded Video Conferencing Network
Strong Health Videoconference/ Telemedicine Network 08/00
1 SMH/ED Legacy H320 Via Point-to- Point CAT 5/RPM Connection 1. Peds Conf Rm 2. Ortho Conf Rm 3. Inf Dis Conf Rm Roamer 4. Board Room rsi 5. Whppb Aud PbTel 4500 6. K-307 Aud 1 H.320/ 7. K-207 Aud Ascend RPM 8. Upper Aud , J 9. Lower Aud F cTd 4500 10. ACF Conf Rm A Legacy Videoconference 11. ACF Conf Rm B H.320/ Ajcend RPM Network 12. ACF Conf Rm C 13. ACF Conf Rm D 14. ACF Conf Rm E 15. Human Rev Board 16. MRB Aud 17. 1-9555 Conf Room
Jeannie L. Christensen Page 80 of 81 Capstone Thesis BIBLIOGRAPHY
1 Telemedicine: What the Future Holds when you're III (1998). MaryAnn
Karinch pp: 33-35
2 Telemedicine: Its Place on the Information Highway; Frederick Williams and Mary Moore; August 1995; http://naftalab.bus.utexas.edu/nafta- 7/telepap.html
3 Telemedicine and TeleHealth Networks, April 1998. "Moving forward,
ahead." looking back: telemedicine in the year Jay H. Sanders, M.D. 4 http://www.telephonyworld.com/vonh323/vonh323.htm
5 Proposal to Establish Telemedicine at the University of Rochester Medical Center, June 1997. Karol Marciano, Michael Myers, Richard Powers.
6 http://www.elemedia.com - H.323 Standards
7 http://computinqcentral.msn.com/topics/telephonv/questions.asp
8 Stars and Bars: "Corrections-Based Telemedicine Programs Top Most-
Active List; by Terry Wheeler; Telemedicine Today, June 98; pp. 38 -39 9 Prison Telemedicine to Springtown; by Ace Allen, M.D.; Telemedicine
Today, June 1998; pp. 40 -42
10 http://tie.telemed.org/scripts/search/TIEmap.html-Telemedicine
Informatio Exchange
1 1 http://www.technoloqydecisions.com/hipaa.pdf - HIPAA regulations
12 http://www.imtc.org/h320.htm - H.320 and H.323 standards 13 http://telemedtodav.com/articlearchive/articles/ 14 http://www.atmeda.org/search/search.htm 1 5 http://www.nap.edu/readingroom/books/ftr/5302.html - For the Record: Protecting Electronic Health Information 16 http://www.iitf.nist.gov/ipc/privacv.htm - Executive Summary, Options for Promoting Privacy on the National Information Infrastructure Draft for Public Comment Information Policy Committee National Information Infrastructure Task Force, April 1997 17 http://www.proginet.com/HIPAA.htm 18 http://www.nationalcpr.org/UShouse.html - Medical Privacy Bills 106th Congress National Coalition for Patient Rights (CPR) Legislative Score Card
Jeannie L. Christensen Page 81 of 81 Capstone Thesis